Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quality Life Services - Chicora during CMS and state inspections, most recent first.
The facility failed to provide a clean, safe, comfortable, and homelike environment for nine residents. Surveyors observed missing paint with exposed drywall, damaged flooring around a commode with subfloor visible, gouged floors, a closet door with a hole and jagged wood, peeling paint in a restroom, wall gouges, exposed sheetrock, and an unattached radiator cover. The DON stated there was no policy specific to safe, clean, and homelike conditions, and the NHA confirmed the deficiency.
A resident with paraplegia, diabetes, confusion, and wandering behavior was identified as an elopement risk, yet was found in an enclosed courtyard area without the facility’s knowledge after being last seen near the nurse’s station. Staff statements confirmed the resident had accessed the courtyard and became stuck in a wheelchair, and the DON later confirmed the facility failed to ensure adequate supervision.
Surveyors found that a resident dining room near the kitchen was being used to store maintenance equipment and tools, including carts, unattached hand railings, a nail gun, a drill with bits, metal ratchets, scraping tools, a shop vacuum, and fans, while the room’s doors were not locked despite signage stating it was closed. The DON stated there was no policy specific to maintaining a safe, clean, and homelike environment, and a project manager explained that the equipment was related to an ongoing nighttime renovation project and acknowledged that the maintenance equipment had not been secured behind a locked door as required.
A resident with muscle weakness and a need for assistance with personal care sustained superficial burns to the thighs and abdomen after hot tea was spilled during dinner service. Dietary staff poured hot water for beverages without checking temperatures and then moved to the opposite side of the dining room, with their backs turned when the resident cried out. A tablemate reported that a kitchen staff member had just poured hot water into the resident’s cup and then continued serving others before the cup was found tipped over. At the time, two dietary staff were in the dining room and the assigned aide was occupied with another resident, and the NHA confirmed that water temperatures were not checked prior to service, resulting in inadequate supervision and a burn injury.
Surveyors found that a COVID-positive resident with COPD and other conditions was ordered and care planned for droplet precautions per facility policy, which required appropriate signage and a closed door. Observations showed that, although droplet precaution signage was posted, the resident’s door remained wide open to the hallway on multiple checks. An RN acknowledged the door should remain closed to prevent cross contamination, and the DON confirmed the facility failed to follow droplet precautions for this resident.
The facility did not maintain comfortable air temperature levels in a resident room and two common areas, despite having an Extreme Weather policy addressing risks of excessive cold for geriatric residents. After the boiler, the facility’s heat source, required resetting, subsequent observations with the Maintenance Director showed temperatures of 68°F in a resident room, 67.3°F in a common room, and 70.5°F in the dining room. The NHA acknowledged that these conditions did not meet the requirement to provide a safe, comfortable, and homelike environment for residents.
A resident with dementia, depression, and anxiety, care planned as an elopement risk and wanderer, exited a locked memory unit by following their husband, who knew the door code and left the unit without checking behind him. The resident, who was documented as rarely/never understood and did not have a completed BIMS, was later found ambulating in another hallway approximately 36 feet from the memory unit and was returned by staff. Facility records showed behavioral notes without exit-seeking behaviors, and leadership acknowledged that supervision was insufficient to prevent this elopement.
Unsanitary conditions were observed in the main kitchen walk-in cooler when surveyors found brown debris on 2 fans and on the ceiling. The Dietary Director/Manager confirmed the debris and acknowledged that sanitary conditions were not maintained, creating the potential for cross contamination.
A resident with diabetes and other conditions sustained a burn after being served hot coffee by the Activities department without the temperature being checked, while another resident with dementia and a history of wandering eloped twice due to lack of individualized supervision and interventions. Facility staff and leadership confirmed failures to follow policies on accident prevention and elopement.
A facility failed to provide trauma-informed care for three residents with PTSD by not identifying or addressing triggers that could lead to re-traumatization. One resident's record showed PTSD, anemia, and paranoid schizophrenia, but the care plan did not include trauma-informed interventions; another resident's Social Services assessments incorrectly stated there was no trauma/PTSD history and the care plan did not address triggers; a third resident's care plan noted PTSD related to the Vietnam War but still did not identify triggers or prevention for re-traumatization. The SW confirmed the missing or inaccurate documentation, and the DON confirmed the failure.
Inaccurate care plans and assessments for bedrail use: Three residents were observed with bilateral side rails or enabler bars on their beds, but the records did not show accurate ongoing assessments or care plans with measurable objectives, timetables, and specific interventions for the devices. One resident had HTN, muscle weakness, and needed help with personal care; another had anemia, Parkinson's disease, and depression; and a third had HTN, DM, and ESRD. The RNAC confirmed the deficiencies in the resident records.
Missing Annual Performance Evaluations for Nurse Aides: The facility failed to complete annual performance evaluations at least once every 12 months for four nurse aide personnel records. Review of the records showed each aide had a hire date documented, but no annual evaluation was present, and HR confirmed the omission during interview.
The facility failed to hold QAA/QAPI meetings at least quarterly with all required committee members for three reviewed quarters. Review of minutes, sign-in sheets, and attendance records showed the Infection Preventionist was absent from the meetings, and the Clinical Services Specialist confirmed the deficiency during interview.
Infection prevention and control was not properly implemented when an LPN used the same Dakins-soaked gauze on separate wounds during a dressing change for a resident with anemia, paraplegia, and hyperlipidemia. The facility also failed to have contact isolation orders for two residents with head lice, and for one of those residents the care plan did not include contact precautions; the DON confirmed the deficiencies.
Failure to Assess and Order Self-Administration of Medications: A resident with lung cancer, respiratory failure, and CKD had meds left unattended at the bedside, including pills and liquid medication. The RN confirmed the meds were stored in the room inappropriately, and the record lacked a physician order, assessment, or care plan for self-administration.
Failure to assess scoop mattress as possible restraint: A resident with anemia, Parkinson’s disease, and depression was ordered a scoop mattress for positioning, comfort, and safety in bed. The resident was dependent for rolling, the mattress had raised edges observed during survey, and the record lacked assessments or ongoing evaluations to determine whether the device functioned as a restraint; the RNAC confirmed the lapse.
A resident with HTN, DM, and ESRD had a physician order for a Dexcom G7 CGM sensor, but the current care plan did not include goals or interventions related to the device. The RNAC confirmed the care plan was not comprehensive and did not meet the resident’s care needs.
The facility failed to maintain consistent and complete dialysis communication records for two residents receiving dialysis. One resident had ESRD, DM, and HTN with ordered dialysis three times weekly, but several dialysis communication forms were incomplete or missing. Another resident with end stage kidney disease and dependence on renal dialysis had no completed dialysis communication records. The LPN and DON confirmed the missing and incomplete communication.
Improper Storage of Opened Tuberculin Vials in Medication Room: An observation of the Memory Lane medication room refrigerator found two opened tuberculin multiple-dose vials that were not labeled with the date opened as required. Facility policy stated that certain multiple-dose injectable vials require a shortened expiration date to ensure medication purity and potency, and an LPN confirmed the improper storage.
Failure to designate a qualified IP: The facility did not have an onsite qualified individual responsible for the infection prevention and control program during a gap after the prior IP’s last day of work and again after the DON became Interim DON. The DON confirmed in interview that she served as IP and ADON for a period, then became Interim DON, leaving the facility without a designated qualified person responsible for infection prevention and control.
Failure to Administer Consented Pneumococcal Vaccine: The facility failed to follow a resident’s consent for the pneumococcal vaccine and did not administer it in a timely manner. The resident had HTN, DM, and dementia, and the immunization record did not show the vaccine was offered or received. The DON confirmed the consent had been obtained, but the vaccine was never given as requested and consented to.
Missing Communication Training for a Nurse Aide The facility failed to provide required effective communication training for one of five staff members reviewed, a NA. Review of the employee’s personnel and education records showed no evidence of the required training, and the Clinical Services Specialist confirmed the omission during interview.
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program and the State Survey Agency in the front hallway. Observations showed the Ombudsman posting was missing an email address, and the SSA posting was missing the agency address and email. An LCS confirmed the incomplete postings during interview.
The facility failed to ensure all nursing staff received required abuse/neglect education before working and annually, and did not timely identify, report, or investigate allegations that an LPN administered medications without orders, resulting in residents being overly sedated and unable to eat or wake up. The LPN continued to work after allegations were made, and the facility did not promptly suspend the staff member or initiate an investigation.
Staff reported that an LPN was administering medications such as melatonin and Tylenol to residents without proper orders, leading to residents appearing sedated, unable to eat, and an increase in deaths on the memory impaired unit. Despite these reports, facility leadership delayed reporting the allegations to required authorities for ten days, failing to follow mandated procedures for timely investigation and notification.
The NHA and DON failed to implement the facility's abuse and neglect policy and did not report alleged criminal activity involving an LPN to authorities, resulting in immediate jeopardy for all residents. This deficiency was identified through review of job descriptions, records, and staff interviews, and confirmed during an interview with the Chief Nursing Officer.
Four direct care nurse aides did not receive the minimum 12 hours of annual training required by regulation, as confirmed by facility documentation and staff interviews.
A resident with severe cognitive impairment and high fall risk experienced an unwitnessed fall resulting in injury. Despite facility policy requiring prompt notification, the physician was not informed until three days later and the family was notified twenty days after the incident. Staff interviews and documentation confirmed the delay in communication and failure to follow established protocols.
A resident with dementia and anxiety was administered Ativan PRN over an extended period without a 14-day stop date or documented physician rationale for continued use. Non-pharmacological interventions were not documented prior to medication administration, and staff confirmed that facility policy was not followed regarding psychotropic medication use and documentation.
A resident with severe cognitive impairment and multiple diagnoses required substantial assistance with toileting and hygiene. After a fall resulting in injury, the clinical event was documented by the Nursing Home Administrator, who is not a nurse, contrary to professional standards of practice. Staff interviews confirmed that only nursing personnel should document such events.
A resident with cognitive impairment and multiple diagnoses was given PRN acetaminophen for pain without documented evidence of a physical assessment, vital signs, or non-pharmacological interventions prior to administration. Staff interviews confirmed that required assessments and documentation were not completed, and the DON acknowledged the failure to follow facility policy and state regulations.
A resident with severe cognitive impairment and high fall risk experienced a fall while unsupervised during toileting, resulting in injury. Required fall prevention interventions, timely physical assessment, and neurological checks were not implemented as per policy. There were also significant delays in notifying the family and physician, and staff failed to document and monitor the resident as required.
A resident with a documented Tylenol allergy was given Tylenol by an LPN who did not check the chart before administration, resulting in a significant medication error. The error was identified during charting, and facility leadership confirmed the failure to follow medication administration protocols.
The facility did not provide required QAPI training to one direct care staff member, as confirmed by review of education records and staff interviews. This failure was identified during a review of staff development practices and cited under relevant state regulations.
A resident with multiple diagnoses who regularly visited his wife in an attached personal care unit was found outside the skilled facility, prompting a new physician's order requiring staff escort for such visits. The care plan was not updated to reflect the resident's preference for visiting his wife or the new escort requirement, as confirmed by the Nursing Home Administrator.
A resident with heart failure, anxiety, and depression reported being handled roughly by a nurse aide during care, describing the incident as sexual abuse and expressing significant emotional distress. Although the event was reported as physical abuse and the staff member was suspended, the specific allegation of sexual abuse documented by an LPN was not communicated to the DON and was not investigated, resulting in a failure to follow facility policy for abuse investigation.
The facility failed to properly label and date food items and maintain clean equipment in the Main Kitchen, as observed by surveyors. Unlabeled whipped topping, pies, and turkey were found, and a fan used for drying dishes was covered in a gray, fuzzy substance, indicating non-compliance with food safety and sanitation policies.
The facility failed to communicate necessary resident information to the receiving health care provider for five residents transferred to a hospital. The missing documentation included care plan goals, advanced directives, and specific care instructions, despite the residents having conditions like Alzheimer's, diabetes, and coronary artery disease. The Director of Nursing confirmed this failure, violating resident rights.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers or therapeutic leaves for four residents with conditions such as Alzheimer's, dementia, and coronary artery disease. The facility's policy requires written notification at the time of transfer, but no documentation was found to confirm this was done.
The facility failed to reassess a resident for safe smoking practices and did not adequately monitor elopement prevention devices for several residents. A resident with a history of heavy smoking and medical conditions was not reassessed for smoking safety as required. Additionally, Wanderguard devices for residents with cognitive impairments were not monitored according to physician orders, with multiple instances of missed checks. These deficiencies were confirmed by the DON.
The facility failed to lock a medication room refrigerator containing narcotics and did not label open medications with a date. An LPN confirmed these issues. Additionally, medications and treatments were not stored properly on two medication carts, with expired insulin and unlabeled medications found. An LPN acknowledged these deficiencies.
The facility failed to monitor personal refrigerators for two residents, did not implement proper infection control during a dressing change for a resident with paraplegia, and neglected to review infection control policies annually. Additionally, the facility did not notify residents or their representatives about COVID-19 and Norovirus outbreaks, as confirmed by the DON.
Two residents with significant assistance needs were left without timely help during meals, compromising their right to a dignified dining experience. One resident with Alzheimer's and malnutrition required substantial assistance, while another with dementia and diabetes was fully dependent on staff for eating. Observations showed both residents unattended with meals in front of them, while staff were busy assisting others. A nursing assistant admitted to not reporting the need for more staff, and the Assistant Director of Nursing confirmed the deficiency.
A resident with hyperlipidemia and depression developed skin issues, including scratches and a yeast infection. An aide and an RN noted these conditions and applied creams, but the facility failed to notify the physician of the change in condition. This deficiency was confirmed by the DON.
A facility failed to ensure a resident with moderate cognitive impairment understood the SNF ABN form, as required by regulations. The resident, with a BIMS score of 8, signed the form without adequate explanation, violating resident rights and admission policies.
A facility failed to obtain a physician order and develop a resident-centered care plan for placing a resident's bed against the wall. The resident, diagnosed with coronary artery disease, hypertension, and hyperlipidemia, had a care plan to prevent falls, but it did not include the bed placement. This oversight was confirmed by staff and violated facility policy and resident rights, which prohibit restraints without medical necessity.
A resident with an indwelling urinary catheter did not have a privacy cover on their catheter bag, as required by facility policy. The resident, diagnosed with neurogenic bladder, had a physician's order for a foley catheter. An LPN confirmed the absence of the privacy cover during an observation.
Facility staff failed to maintain communication with the dialysis center for two residents, leading to incomplete dialysis communication sheets. An LPN admitted to not filling out the top portion of the sheets, while an RN confirmed the necessity of completing them. The DON acknowledged the deficiency in communication and documentation for the residents receiving dialysis.
A resident did not receive their prescribed Mercaptopurine on two consecutive days due to unavailability, and the physician was not notified of the missed doses. This was confirmed by the DON, indicating a failure to prevent significant medication errors as per facility policy and state regulations.
The facility did not conduct QAA meetings with all required members from January to March 2024. The QAPI Committee, as per policy, should include members like the Medical Director and Infection Preventionist, who were absent. This was confirmed by the Nursing Home Administrator.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for nine residents. During review of facility policy, the Director of Nursing stated the facility did not have a policy specific to safe, clean, and homelike conditions. Survey observations found multiple environmental deficiencies in resident rooms: one former resident room had large patches of missing paint with exposed drywall, and the floor around the in-room commode was damaged with subfloor visible in spots. Another room assigned to four residents had numerous gouges in the floor and a wooden closet door with a hole approximately four inches across and jagged wood present. A room assigned to two residents had a large section of peeling paint in the restroom and gouges on the wall behind the bed. Another room assigned to two residents had exposed sheetrock and an unattached radiator cover. The Nursing Home Administrator confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for nine of sixteen residents.
Failure to Supervise Resident at Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision for a resident identified as an elopement risk who did not reside on a secured unit, resulting in the resident being found in an enclosed secure courtyard area without the facility’s knowledge. The resident had diagnoses including paraplegia and diabetes, and the wandering/elopement risk evaluation noted increased confusion, wandering throughout the facility, and going outside with an electric wheelchair. The care plan identified aimless wandering and included monitoring for entry into restricted areas unattended or statements about going outside, with interdisciplinary review if needed. Facility investigation information stated the resident was not accounted for for approximately 15 minutes after being last seen in the common area near the nurse’s station. One nurse aide stated the resident was found in the courtyard stuck behind the door and in a chair and that the nurse on the floor was notified. Another nurse aide stated the resident was outside the courtyard doors and his wheelchair was stuck on the cement, and staff assisted him back to his room. The nursing home administrator and DON later confirmed that the facility failed to make certain the resident received adequate supervision that resulted in an elopement.
Unsecured Maintenance Equipment Stored in Resident Dining Room
Penalty
Summary
Surveyors determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by improperly storing maintenance equipment in an unsecured resident dining room located directly outside the kitchen. During a tour, the dining room was observed to contain maintenance equipment and carts, unattached resident hand railings, a nail gun, a drill with bits, a case of metal ratchets and pieces, scraping tools, a shop vacuum, fans, and other repair tools, while the doors to the room were not secured with locks at either the front or side entrances. Although a sign on the doors indicated the room was closed and to keep doors closed when not in use, the equipment remained accessible in this resident area. The DON reported that the facility did not have a policy specific to maintaining a safe, clean, and homelike environment, and the project manager confirmed that the equipment was related to an ongoing renovation and painting project that had been occurring at night for several weeks to give the facility a makeover, and acknowledged that the facility failed to secure the maintenance equipment behind a locked door as required. No specific residents, medical histories, or clinical conditions were identified in the report as being directly involved in or affected by this deficiency.
Inadequate Supervision and Hot Beverage Handling Resulting in Resident Burn
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment, resulting in a hot liquid burn to one resident. Facility policy on Accidents and Incidents stated that a safe environment would be provided for all residents. The resident involved had diagnoses including high blood pressure, muscle weakness, and a need for assistance with personal care, as documented on an MDS assessment. On the date of the incident, a change in status note recorded that the resident was served a dinner tray, took her tea to drink, and dropped it on herself, resulting in burns to multiple areas including the right thigh, left inner and outer thigh, and right and left lower and upper abdominal quadrants, with specific burn measurements documented. An Emergency Department note stated that a staff member at the nursing home accidentally dropped hot water for tea on the resident, causing a superficial first-degree burn to the upper abdomen and right thigh, with no blistering. Witness statements from dietary staff indicated that hot beverages were poured for residents without checking the temperature of the coffee/tea water, and that the dietary aide was on the other side of the dining room with her back to the resident when the resident cried out. Another statement from the resident’s tablemate reported that a kitchen staff member poured hot water into the resident’s cup, moved on to other tables, and was on the other side of the dining room when the resident screamed and the cup was seen tipped over. The Nursing Home Administrator confirmed that kitchen staff did not check the temperature of the water before service and that, at the time of the incident, two dietary staff were in the dining room while the assigned nurse aide was occupied bringing another resident to the dining room, resulting in inadequate supervision and a burn injury to the resident.
Failure to Maintain Closed Door for Resident on Droplet Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for droplet precautions for one resident on isolation precautions. Facility policy titled "Covid Positive Steps" dated 12/1/25 required that a COVID-positive resident have an appropriate sign on the door, the door remain closed, vitals taken every shift while in isolation, isolation maintained for 10 days, and appropriate PPE stationed by the room. The resident, who had diagnoses including hypertension, COPD, and depression, was admitted on an unspecified date and tested positive for COVID-19 on 3/6/26. Physician orders dated 3/6/26 and the resident’s care plan dated 3/6/26 directed that droplet precautions be maintained every shift. On 3/9/26 at 11:59 a.m., surveyor observation showed that the resident’s door displayed droplet precaution signage but was standing wide open to the outer hallway. At 12:00 p.m., an RN confirmed that the resident was COVID-positive, on droplet precautions, and that the door should remain closed at all times to prevent cross contamination potential. A subsequent observation at 1:17 p.m. again found the door wide open despite the droplet precaution signage. At 1:20 p.m., the DON confirmed that the facility failed to follow droplet precautions for this resident in isolation precautions. The deficiency was cited under 28 Pa Code: 201.14(a), 201.28(b)(1)(e)(1), and 211.10(d).
Failure to Maintain Comfortable Air Temperatures in Resident Room and Common Areas
Penalty
Summary
The facility failed to ensure comfortable air temperature levels in one resident room and two resident common areas, as required by its policy and resident rights to a safe, clean, comfortable, and homelike environment. The facility’s Extreme Weather policy dated 12/1/25 stated that excessive cold for lengthy periods can negatively impact center operations, poses severe potential harm to confused exit-seeking residents, and that geriatric residents are at greater risk of hypothermia because their bodies do not effectively regulate internal temperatures. The Nursing Home Administrator reported that on 1/25/26 the facility’s boiler, which serves as the heat source, needed to be reset. During observations on 1/28/26 from 12:15 p.m. to 12:45 p.m. with the Maintenance Director, air temperatures were measured at 68°F in one resident room, 67.3°F in the Miller Common Room, and 70.5°F in the dining room. In an interview later that day, the Nursing Home Administrator confirmed that the facility failed to ensure comfortable air temperature levels in one of 34 resident rooms and two of three resident areas.
Elopement of Cognitively Impaired Resident From Locked Memory Unit
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an elopement for a resident identified as an elopement risk and wanderer. Facility policy on Elopement Prevention required that residents be properly assessed and care planned to prevent accidents related to wandering or elopement, including completion of a Wandering Risk Assessment upon admission, readmission, quarterly, and as needed, and development of a comprehensive elopement prevention care plan when warranted. The resident’s MDS showed diagnoses of depression, dementia, and anxiety, and Section C0100 indicated the resident was rarely/never understood, with the BIMS not completed. The resident’s care plan, dated 5/22/24, identified the resident as an elopement risk/wanderer based on a history of attempts to leave home unattended prior to admission and included interventions such as identifying patterns of wandering and monitoring the resident’s frequent location. On the date of the incident, documentation showed the resident was observed ambulating outside the locked memory unit on another resident hallway, approximately 36 feet from the memory unit. An interview revealed that the resident’s husband had visited and exited the locked unit, believing the resident was far enough from the door when he left and stating he was in a hurry and did not look behind him. A witness statement from an LPN indicated the resident followed the husband out of the unit and staff later noticed the resident in the hallway and returned the resident to the locked memory unit. Review of progress notes from 6/1/25 through 1/28/26 showed documented behaviors for the resident but none were exit-seeking. The DON stated that when she worked in the locked memory unit, the resident’s husband would come and go because he knew the door code. The NHA and DON confirmed that the facility failed to ensure each resident received adequate supervision, resulting in this elopement event.
Unsanitary Conditions in Walk-In Cooler
Penalty
Summary
The facility failed to maintain sanitary conditions in the designated main kitchen walk-in cooler. During an observation of the main kitchen, surveyors noted brown debris on (2) fans in the walk-in cooler and brown debris on the ceiling in the walk-in cooler. During interview, the Dietary Director and Dietary Manager, Employee E11, confirmed the brown debris in the walk-in cooler and acknowledged that the facility failed to maintain sanitary conditions, which created the potential for cross contamination.
Failure to Provide Adequate Supervision Resulting in Resident Burn and Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for two residents, resulting in one resident sustaining a burn and another resident eloping from the facility. For the first incident, a resident with diagnoses including diabetes, depressive disorder, and hypertension was admitted to the facility and had physician's orders for restorative dining. During an activity in the dining area, coffee provided by the Activities department was served without checking its temperature. The resident spilled the coffee in her lap, resulting in a red, blistered burn. The incident was reported by a CNA, and it was confirmed that the coffee temperature was not measured prior to serving. In the second incident, a resident with anemia, renal insufficiency, and vascular dementia, who had a known history of wandering and was assessed as an elopement risk, was not provided with adequate supervision or individualized interventions to prevent elopement. The resident's baseline care plan did not include specific interventions for supervision or elopement prevention. Despite being fitted with a wander guard, the resident was able to remove it and eloped to another unit within the facility. On a subsequent occasion, the resident exited the facility through the front doors, triggered the wander guard alarm, and was found outside by another resident's family member. Staff interviews, facility policy reviews, and documentation confirmed that the facility did not follow its own policies regarding accident prevention and elopement. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of adequate supervision and failure to implement resident-centered interventions for the identified elopement risk, as well as the failure to ensure a safe environment in the dining area, which resulted in the resident's burn.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma informed care for three residents with PTSD by not identifying or addressing triggers that could lead to re-traumatization. Review of the record for one resident showed diagnoses including PTSD, anemia, and paranoid schizophrenia, and the current care plan addressed delirium but did not include a trauma informed care plan for PTSD or potential triggers. During interview, the Social Worker confirmed that this resident did not have a trauma informed care plan addressing PTSD or identifying triggers and prevention for re-traumatization. For another resident, the clinical record showed diagnoses of dementia, PTSD, and muscle weakness, but multiple Social Services assessments documented that the resident did not have a history of trauma/PTSD. The resident's care plan also failed to address PTSD by identifying triggers or how to avoid them, and the Social Worker confirmed both the inaccurate assessments and the missing care plan content. For a third resident with diagnoses including anemia, PTSD, and renal insufficiency, the care plan stated the resident had a history of actual trauma related to the Vietnam War and would feel safe and comfortable, but it did not identify triggers or prevention for re-traumatization. The Social Worker confirmed this care plan also failed to address PTSD triggers and prevention.
Inaccurate care plans and assessments for bedrail use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments for bedrail use for three residents. Resident R1, admitted with diagnoses of high blood pressure, muscle weakness, and need for assistance with personal care, was observed on 12/1/25 with bilateral side rails on the bed, but the comprehensive care plan did not include measurable objectives, timetables, or specific interventions/services for bed rail use. Resident R63, admitted with diagnoses of anemia, Parkinson's Disease, and depression, was also observed on 12/1/25 with bilateral side rails on the bed; the care plan dated 12/24/22 stated the resident used bilateral 1/2 rails for bed mobility, repositioning, and to promote independence. Resident R92, admitted with diagnoses of high blood pressure, diabetes mellitus, and End-Stage Renal Disease, was observed on 12/1/25 with bilateral enabler bars on the bed, but the clinical record did not reveal an ongoing accurate assessment for the enabler bar usage and the comprehensive care plan did not include measurable objectives, timetables, or specific interventions/services for use of enabler bars. During interview, the RNAC confirmed that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and address the risks associated with bedrail usage for these three residents.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for four of four nurse aide personnel records, including Employees E12, E13, E14, and E15. Review of each personnel record showed a hire date for the employee, but no annual performance evaluation was included at least every 12 months as required. During an interview on 12/3/25 at 12:47 p.m., Corporate Human Resources Employee E7 confirmed that the facility failed to complete annual performance evaluations at least every 12 months for these four nurse aide personnel records.
QAA Meetings Lacked Required Member Attendance
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required members for three of three quarters in 2025. Review of the QAA minutes, sign-in sheets, and attendance records for Quarter One, Two, and Three of 2025 showed that the Infection Preventionist was not in attendance at the meetings. During an interview on 12/4/25 at 1:30 p.m., the Clinical Services Specialist confirmed that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all required committee members for all three quarterly meetings reviewed.
Infection Control Failures During Wound Care and Lice Precautions
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified when cross contamination occurred during a dressing change for a resident with multiple wounds. The resident had diagnoses including anemia, paraplegia, and hyperlipidemia, and had physician-ordered wound care for the coccyx, left ischium, and right ischium that required cleansing each wound separately with Dakins solution and dressing changes twice daily or as needed. During observation of the dressing change, an LPN cleansed the right ischium wound with Dakins-soaked gauze and then used the same piece of gauze to cleanse the coccyx wound. The LPN confirmed the observation and acknowledged that infection control practices were not followed to prevent cross contamination. The facility also failed to ensure that contact precautions were ordered for two residents with head lice and failed to ensure that contact precautions were care planned for one of those residents. One resident with dementia, high blood pressure, and depression was documented as having lice in the hair, and the care plan included contact precautions for head lice, but the physician orders did not include contact isolation. Another resident with Parkinson's disease, dementia, and high blood pressure was documented as having head lice in the beard of the face and was placed on contact precautions per facility infection control policy, but the physician orders again did not include contact isolation and the care plan did not include interventions or identification of contact precautions. The DON confirmed these failures during interview.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether it was safe for one resident to self-administer medications. The facility policy on self-administration of medications stated that residents may self-administer if the interdisciplinary team determines the practice would be safe and there is a prescriber’s order. The resident was admitted with diagnoses including malignant neoplasm of the upper lobe of the right bronchus or lung, respiratory failure, and chronic kidney disease. During observation, two medicine cups were found at the bedside table, one containing liquid and the other containing three pills. The RN confirmed the pills were fish oil, Zoloft, and Movantik, and the liquid was MiraLax, and also confirmed she had left the medications unattended at the bedside. Review of the clinical record found no physician order, assessment, or plan of care addressing self-administration of medications, and the RN confirmed the medications were stored in the room inappropriately and that the resident did not have the required assessment, order, or plan of care.
Failure to Assess Scoop Mattress as Possible Restraint
Penalty
Summary
The facility failed to identify a scoop mattress as a possible restraint and failed to assess the resident’s functional status to determine whether the scoop mattress was a restraint for Resident R63. Facility policy defined physical restraints as any manual method or mechanical device, material, or equipment attached to or adjacent to the elder’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to one’s body. The clinical record showed Resident R63 was admitted to the facility with diagnoses of anemia, Parkinson’s disease, and depression, and the MDS dated 9/12/25 coded the resident as dependent for rolling left and right. A physician order dated 10/21/24 indicated the resident was provided a scoop mattress for positioning, comfort, and safety while in bed. During observation on 12/1/25 at 10:05 a.m., the resident’s mattress was seen with bilateral raised edges on the top and bottom portions. Review of the clinical record failed to identify any assessments or ongoing evaluations for the use of the scoop mattress. During interview on 12/3/25 at 1:08 p.m., the RNAC confirmed the facility failed to identify the scoop mattress as a possible restraint and failed to assess the resident to determine whether its use was a restraint.
Failure to Include Blood Glucose Sensor Care in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to meet the care needs of Resident R92. Review of the clinical record showed the resident was admitted to the facility and had an MDS dated 10/23/25 with diagnoses of high blood pressure, DM, and ESRD. A physician order dated 5/6/25 directed staff to apply a Dexcom G7 Sensor transdermally every evening shift every 10 days for DM, but the resident’s current care plan did not include goals or interventions related to the wearable continuous blood glucose monitor. During an interview on 12/3/25 at 1:11 p.m., the RNAC confirmed that the facility failed to develop a comprehensive care plan to meet Resident R92’s care needs.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two residents who required dialysis services. Resident R92 had diagnoses including high blood pressure, diabetes mellitus, and ESRD, and a physician order indicated dialysis treatment at an outside facility every Monday, Wednesday, and Friday. The resident’s clinical record did not include complete dialysis communication forms for 11/19/25, 11/21/25, and 11/25/25, and no communication form was located for 11/5/25. Resident R13’s record showed diagnoses of end stage kidney disease, dependence on renal dialysis, and anxiety disorder, and a physician order indicated dialysis every Tuesday, Thursday, and Saturday. Review of R13’s dialysis communication records showed no completed communication records. During interview, the LPN and the DON confirmed the facility failed to provide consistent and complete communication with the dialysis center for both residents.
Improper Storage of Opened Tuberculin Vials in Medication Room
Penalty
Summary
The facility failed to properly store medications in one of three medication rooms, the Memory Lane Medication Room. During an observation of the Memory Lane Medication Room refrigerator, two tuberculin multiple dose vials were found opened and not labeled with the date opened as required. Facility policy on storage of medications dated 10/13/25 indicated that certain medications, including multiple dose injectable vials, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. An LPN confirmed the observation and acknowledged that the facility failed to properly store medication in the Memory Lane Medication Room.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified onsite individual responsible for implementing the infection prevention and control program during the periods when the prior Infection Preventionist employee’s last day of work was 10/4/25 and before the DON assumed the Infection Preventionist role on 10/13/25, as well as after the DON became Interim DON on 11/16/25 through the present. During interviews on 12/5/25, the DON stated that she served as the Infection Preventionist and Assistant DON from 10/13/25 until 11/16/25, when she became Interim DON, and confirmed that the facility did not have a qualified individual onsite responsible for infection prevention and control during the identified periods.
Failure to Administer Consented Pneumococcal Vaccine
Penalty
Summary
The facility failed to follow resident consent for pneumococcal vaccination and failed to administer the vaccination in a timely manner for one resident. Facility policy for Standing Orders for Administering Pneumococcal Vaccine to Adults dated 10/13/25 directed staff to identify adults in need of pneumococcal polysaccharide vaccine, document the date given, manufacturer, lot number, site, route, and the name and title of the person administering it, or record the reason for non-receipt if it was not given. Resident R65 was admitted to the facility with diagnoses including high blood pressure, diabetes, and dementia. The resident’s immunization record did not show evidence that the pneumococcal vaccine was offered and received. The clinical record contained a Resident Pneumococcal Vaccine Consent/Declination Form dated 8/30/23 documenting consent for the vaccine, but the vaccination was never administered. During interview on 12/4/25 at 11:00 a.m., the DON confirmed that consent had been obtained, but the vaccine was not given as requested and consented to for Resident R65.
Missing Communication Training for Nurse Aide
Penalty
Summary
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members was not met when the facility failed to provide required communication training for one of five staff members reviewed, Nurse Aide Employee E15. Review of Employee E15's personnel record showed a hire date of 1/6/23, and review of the employee's education documents on 12/3/25 at 12:00 p.m. did not include evidence of the required communication training. During an interview on 12/3/25 at 2:30 p.m., the Clinical Services Specialist, Employee E5, confirmed that the facility failed to provide training on effective communication for Employee E15.
Incomplete Posting of State Agency and Ombudsman Contact Information
Penalty
Summary
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program and the State Survey Agency in the front hallway as required. During observations on 12/4/25, the posted Ombudsman information did not include the Ombudsman's email address, and the State Survey Agency information did not include the agency's address or email address. During an interview on 12/4/25 at 11:40 a.m., the Clinical Service Specialist, Employee E5, confirmed that the facility had not posted complete contact information for both the State Long-Term Care Ombudsman program and the State Survey Agency.
Failure to Educate Staff and Timely Respond to Abuse/Neglect Allegations
Penalty
Summary
The facility failed to ensure that all nursing staff were educated on abuse and neglect prior to working in the facility and annually, as required by policy. Specifically, one LPN did not receive abuse/neglect education before starting work, and two other nursing staff members did not receive annual abuse/neglect education. This lack of training was confirmed through review of employee files, facility documents, and staff interviews. Additionally, the facility did not complete required onboarding documentation for agency staff prior to their start date. Multiple staff members reported concerns regarding the actions of an LPN working on the memory impaired unit, including allegations that the LPN administered medications such as melatonin and Tylenol to all residents regardless of physician orders. Staff observed that residents appeared more sedated, lethargic, and unable to eat or wake up during the day when this LPN was on duty. There were also concerns raised about an increase in resident deaths and changes in resident conditions, such as hypothermia, that were not properly reported or followed up by nursing staff. Despite these reports, the facility failed to identify, report, and investigate these allegations of abuse and neglect in a timely manner. The facility allowed the LPN who was the subject of abuse/neglect allegations to continue working after the concerns were reported, without immediate suspension or implementation of a supervision plan. The Director of Nursing and Nursing Home Administrator confirmed that they did not initiate an investigation or report the allegations to appropriate agencies promptly. Witness statements and interviews revealed that staff were aware of the allegations but did not report them immediately, and the facility did not obtain witness statements until several days after being notified of the concerns.
Removal Plan
- Review current medical records for any signs of abuse/neglect and interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any is found, follow abuse policy and begin investigation and reporting immediately.
- Interview all staff for allegations of abuse/neglect that have not been reported. If any are identified, begin investigations and reporting immediately.
- Provide education by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on immediate reporting of any allegation/neglect.
- Provide education by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on the immediate suspension of an employee with an allegation of abuse/neglect.
- Provide education by the DON/Designee to Licensed Nursing Staff both in house and agency on the appropriate medication administration and following Physician's orders.
- Audit each resident's Medication Administration Record (MAR) and Treatment medication Record (TAR) to ensure medications and treatments have been administered/given as ordered.
- Review the Abuse/Neglect Policy and update if needed.
- Educate all house staff and agency staff on the abuse/neglect policy and reporting abuse by the DON and/or designee.
- Review all audits and policy changes related to immediate jeopardy at an ad hoc Quality meeting.
- Interview all staff for instances of abuse/neglect that were not reported. Report and investigate any incidents timely.
- Require all licensed nursing staff, not educated, to verify education on physician orders and MAR/TARs.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and timely report criminal allegations of abuse and neglect involving an LPN to local law enforcement and required agencies. Multiple staff members, including housekeepers and nurse aides, reported concerns that the LPN was administering medications such as melatonin and Tylenol to residents without proper orders, resulting in residents appearing sedated, lethargic, and unable to eat or remain awake during the day. Staff also noted an increase in resident deaths on the memory impaired unit during shifts when the LPN was working. These concerns were documented in witness statements and interviews, with specific observations of residents' abnormal behavior and changes in condition, such as hypothermia and excessive sleepiness. Despite these serious allegations and observations, the facility did not promptly initiate an investigation or report the incidents to the Area Agency on Aging, the Department of Health, or local law enforcement as required by state law and facility policy. The Director of Nursing and Nursing Home Administrator were made aware of the allegations but delayed reporting for ten days, only notifying authorities after being prompted during the survey process. The DON dismissed the initial reports as hearsay and gossip, contributing to the delay in addressing the allegations. The failure to act on staff reports and to follow mandated reporting procedures resulted in an immediate jeopardy situation, as the facility did not ensure the protection of residents from potential abuse or neglect. The deficiency was identified through review of facility documentation, staff interviews, and examination of resident records, which confirmed that the facility did not comply with legal and policy requirements for timely reporting and investigation of suspected abuse and neglect.
Removal Plan
- Review current residents' medical records for signs of abuse/neglect by the DON and/or designee. Interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any allegations of abuse/neglect are found, follow abuse policy, and begin investigation and reporting immediately.
- Interview staff for review of abuse/neglect allegations that have not been reported to the DON and/or designee. If any allegations are identified, begin investigation and reporting immediately.
- Update review of Electronic event report for neglect allegation by the DON/designee to accurately reflect concern for Nurse giving Tylenol and Melatonin to all residents on the memory unit whether there is an order or not thus causing potential harm.
- Review Abuse/Neglect Policy, Incidents and Accidents Policy, and reporting criteria by NHA and/or designee and update if needed.
- Educate all house staff and agency staff on the abuse/neglect policy and reporting abuse by the DON and/or designee prior to their next shift worked.
- Audit all residents who have had an allegation of abuse/neglect in the last 30 days by the DON and/or designee to ensure that it was reported appropriately and timely.
- Review all audits and policy changes related to IJ 609 at an Ad hoc Quality meeting.
Failure to Implement Abuse Policy and Report Alleged Criminal Activity Creates Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage and implement the facility's abuse and neglect policy, and did not report alleged criminal activity involving an LPN to the appropriate authorities. This failure was identified through a review of job descriptions, clinical records, and staff interviews. The NHA's job description required oversight of day-to-day operations, ensuring compliance with federal, state, and local standards, and maintaining effective systems for resident care and safety. The DON's responsibilities included nursing management, setting care standards, and ensuring regulatory compliance. Despite these outlined duties, both the NHA and DON did not fulfill their essential roles in upholding the facility's policies and legal requirements. As a result of these actions and inactions, all 95 residents were placed in an immediate jeopardy situation. The facility did not implement its abuse and neglect policy and failed to report the alleged criminal activity, as required by regulations. The deficiency was confirmed during an interview with the Chief Nursing Officer, who was notified of the failures by the NHA and DON. The report cites specific Pennsylvania Codes related to the responsibilities of the licensee, management, and nursing services, which were not adhered to in this instance.
Failure to Provide Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of annual training for nurse aides, as mandated by regulations. Review of the job description and facility documents confirmed that nurse aides are expected to attend all assigned in-service classes. However, documentation for four direct care nurse aides did not show evidence of completing the required annual training hours. During staff interviews, the Chief Nursing Officer confirmed that these nurse aides did not receive the mandated training for the calendar year reviewed.
Failure to Timely Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a physician following a resident's change in condition after a fall. According to the facility's policy, licensed nurses are required to promptly assess and notify the physician and family when a resident experiences a change in condition. In the case reviewed, a resident with severe cognitive impairment, high risk for falls, and multiple diagnoses including anxiety, muscle weakness, and hypertension, experienced an unwitnessed fall while attempting to transfer from the toilet. The resident sustained a skin tear and reported pain and dizziness. Although the incident was documented and the resident's family was eventually notified, the physician was not informed until three days after the fall, and the family was notified twenty days later, contrary to facility policy and regulatory requirements. Staff interviews confirmed that the expected protocol was immediate notification of both the physician and family following such incidents. Documentation revealed inconsistencies in communication and a lack of timely documentation regarding the incident and subsequent actions. The failure to notify the physician and family in a timely manner was acknowledged by both nursing staff and the facility administrator, confirming noncompliance with established resident care policies and state regulations.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. Clinical record review showed that a resident with diagnoses of dementia, anxiety, and high blood pressure was prescribed Ativan 0.5 mg every six hours as needed for a period of three months. The physician's order did not include a required 14-day stop date, nor was there any documented rationale for extending the medication beyond 14 days. The resident received Ativan on 27 occasions in one month and 22 occasions in the following month. Additionally, there was no documentation in the resident's progress notes indicating that non-pharmacological interventions were attempted prior to administering the Ativan. Staff interviews confirmed that facility policy requires the use of non-pharmacological interventions before administering psychotropic medications and mandates documentation of both the interventions and the behaviors. The Chief Nursing Officer acknowledged that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication.
Non-Nursing Staff Documented Clinical Event in Resident Record
Penalty
Summary
The facility failed to follow professional standards of practice in documentation for one resident. A resident with diagnoses of anxiety, muscle weakness, and high blood pressure, and with a severe cognitive impairment, required substantial assistance with toileting and hygiene. The resident experienced a fall while attempting to transfer from the commode to a wheelchair, resulting in a skin tear and headache. The incident was documented as a late entry progress note by the Nursing Home Administrator, who is not a nurse. Interviews with facility staff confirmed that documentation of clinical events should not be completed by non-nursing personnel, and that the Nursing Home Administrator was not authorized to enter such notes. This failure to adhere to professional standards of documentation was identified for one of eight residents reviewed, as supported by facility policy review, resident record review, and staff interviews.
Failure to Provide Non-Pharmacological Interventions and Assessment Prior to PRN Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was provided with non-pharmacological interventions and a proper assessment prior to administering as-needed pain medication. According to facility policy, all residents should be screened and assessed for pain, with documentation of interventions and responses, especially for those who are cognitively impaired or unable to communicate effectively. In this case, a resident with diagnoses including anxiety, Alzheimer's disease, and high blood pressure, who was unable to verbalize pain, was administered PRN acetaminophen for a reported pain level of 7/10. The clinical record did not show evidence that a physical assessment or vital signs were obtained prior to the administration, nor that non-pharmacological interventions were attempted or documented before giving the medication. Further review of the resident's clinical record revealed that after the administration of acetaminophen, the resident's pain was reassessed and found to be zero. However, later that same day, the resident exhibited a significant change in condition, including a low rectal temperature, bradycardia, hypotension, and unresponsiveness. The nurse notified the family and the resident was sent to the emergency room, where they were admitted for altered mental status and a urinary tract infection. Staff interviews confirmed that the required assessments and documentation of non-pharmacological interventions were not completed prior to administering the PRN medication. Staff interviews also indicated that the resident typically exhibited behaviors such as yelling out and clenching fists, which were used as non-verbal indicators of pain. However, the LPN responsible for administering the medication could not recall if non-pharmacological interventions were implemented or documented prior to giving the acetaminophen. The DON confirmed that the facility did not ensure the resident received non-pharmacological interventions and an assessment before administering pain medication as required by facility policy and state regulations.
Failure to Implement Fall Prevention and Post-Fall Monitoring
Penalty
Summary
The facility failed to implement fall prevention interventions and conduct post-fall monitoring for a resident identified as high risk for falls. The resident had diagnoses including anxiety, muscle weakness, and high blood pressure, and was assessed as having severe cognitive impairment and requiring substantial assistance with toileting and transfers. The care plan specified the use of bed/chair alarms and assistance with toileting every two hours, but these interventions were not consistently implemented. An incident occurred in which the resident fell in the bathroom while attempting to transfer from the toilet to the wheelchair without adequate staff assistance. The fall resulted in a skin tear and complaints of dizziness and headache. Although the facility's policy required immediate physical assessment, timely documentation, and prompt initiation of neurological checks after a fall, these actions were not completed as required. Neurological checks were not started until nearly a day after the fall, and there was no evidence of a timely physical assessment or Q15 minute checks in the clinical record. Additionally, there were significant delays in notifying the resident's family and physician about the fall, with the family being notified 20 days later and the physician three days after the incident. Staff interviews confirmed that required assessments and documentation were not completed promptly, and that staff were unclear about their responsibilities regarding post-fall monitoring and communication. These failures resulted in noncompliance with facility policy and state regulations regarding accident prevention and resident care.
Failure to Prevent Significant Medication Error Due to Allergy
Penalty
Summary
A resident with diagnoses including dementia, aphasia, and malnutrition, and a documented allergy to Tylenol, was administered Tylenol by an LPN without a physician's order and despite the allergy being noted in the clinical record. The LPN did not review the resident's chart prior to administering the medication. The error was discovered when the nurse began charting the administration, at which point it was realized that Tylenol was both not ordered and listed as an allergy for the resident. Facility policy requires that medications be administered as prescribed, following the five rights of medication administration, and that staff verify these rights at multiple points during the process. In this incident, the LPN failed to adhere to these protocols, resulting in a significant medication error. The event was confirmed by both the LPN involved and the Chief Nursing Officer during interviews.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to one of five direct care staff members reviewed. According to the Nursing Assistant job description, staff are required to attend all assigned in-service classes and complete assignments. Review of facility education documents for the year 2024 showed that one nurse aide did not receive QAPI training. This was confirmed by the Chief Nursing Officer during staff interviews, who acknowledged that the required training had not been provided to the identified staff member. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development.
Failure to Update Care Plan After Change in Resident Status
Penalty
Summary
The facility failed to revise the care plan for a resident to accurately reflect the resident's current status and preferences. The resident, who was alert and oriented, had a history of high blood pressure, muscle weakness, and malnutrition. Documentation showed that the resident regularly visited his wife in the attached personal care unit, Vista, and was found there by staff after being reported missing from the skilled facility. Following this incident, a physician's order was obtained allowing the resident to visit his wife if escorted by staff, and both staff and the resident were educated on this requirement. Despite these developments, the resident's care plan was not updated to include his preference for visiting his wife or the new requirement for staff escort during these visits. This omission was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the care plan had not been revised as required by facility policy and regulatory standards.
Failure to Investigate Sexual Abuse Allegation per Policy
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of sexual abuse for one resident. The facility's policy requires immediate notification of the Nursing Home Administrator (NHA) or Director of Nursing (DON), reporting to the state health department, contacting the County Area Agency on Aging, and conducting an internal investigation for all abuse allegations. However, documentation and interviews revealed that a specific allegation of sexual abuse was not fully investigated as required by policy. A resident with diagnoses of heart failure, anxiety, and depression reported being handled roughly by a nurse aide during incontinence care, describing the experience as extremely painful and humiliating. The resident stated that the incident felt like sexual abuse and expressed ongoing emotional distress. The event was initially reported as physical abuse, and the involved staff member was suspended pending investigation. The resident was assessed for physical injury, and law enforcement was contacted. However, the specific allegation of sexual abuse, as documented in a behavior note by an LPN, was not communicated to the DON and was not included in the facility's investigation. Interviews with staff confirmed that the LPN who documented the resident's statement about sexual abuse did not recall reporting it to anyone, and the DON stated she was unaware of the sexual abuse allegation. As a result, the facility did not conduct a complete and thorough investigation into the sexual abuse allegation, failing to follow its own policies and procedures for abuse prevention and investigation.
Deficiencies in Food Storage and Equipment Cleanliness
Penalty
Summary
The facility failed to adhere to its policies on food storage and cleaning, leading to deficiencies in food safety and sanitation. During observations in the Main Kitchen, it was noted that several food items, including packages of whipped topping, lemon meringue pies, and sliced turkey, were not properly labeled and dated as required by the facility's food storage policy. This oversight was confirmed by the Dietary Supervisor. Additionally, a fan used to dry clean dishes was found to be covered in a gray, fuzzy substance, indicating a failure to maintain clean equipment. This was confirmed by a Registered Dietitian, highlighting a breach in the facility's cleaning and sanitation policy designed to prevent foodborne illness.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five out of six residents who were transferred from the facility to a hospital and expected to return. The facility's policy, dated 7/22/24 and last reviewed on 11/8/24, required that a transfer form be completed and appropriate documentation be sent with the resident. However, upon review of the clinical records for Residents R2, R13, R82, R83, and R88, there was no documented evidence that the facility had communicated specific information to the receiving health care provider. This information should have included the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs at the receiving facility. The residents involved had various medical conditions, including high blood pressure, Alzheimer's disease, diabetes, muscle weakness, depression, anemia, dementia, coronary artery disease, and hyponatremia. Despite these conditions, the facility did not provide the necessary documentation to ensure continuity of care during the transfers. The Director of Nursing confirmed during an interview that the facility failed to communicate the required information for these residents, which is a violation of resident rights as per 28 Pa. Code 201.29 (a) (c.3) (2).
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers or therapeutic leaves for four residents. The facility's policy requires that residents be informed in writing about the bed-hold policy at the time of transfer. However, upon review of clinical records, it was found that there was no documented evidence that this information was provided to the residents or their representatives for the specified transfers. The residents involved had various medical conditions, including high blood pressure, Alzheimer's disease, dementia, diabetes, and coronary artery disease. Despite these conditions, the facility did not adhere to its policy of notifying the residents or their representatives about the bed-hold policy during their transfers to hospitals or therapeutic leaves. This deficiency was confirmed by the Director of Nursing during an interview.
Failure to Assess Smoking Safety and Monitor Elopement Devices
Penalty
Summary
The facility failed to assess a resident for safe smoking practices and did not adequately monitor elopement prevention devices for several residents. Resident R42, who has a history of smoking three packs a day and medical conditions including coronary artery disease, hypertension, and hyperlipidemia, was not reassessed for safe smoking after the initial assessment on 6/10/24, despite facility policy requiring such assessments upon admission, quarterly, and as needed. The Director of Nursing confirmed that no further assessments were completed for Resident R42 as required. Additionally, the facility did not ensure proper monitoring of Wanderguard devices for Residents R67, R69, and R72, all of whom have cognitive impairments such as dementia. Physician orders required weekly checks of the Wanderguard battery percentage and checks of placement, function, and skin integrity every shift. However, records show multiple instances where these checks were not completed as ordered, with specific dates and shifts noted for each resident. The Director of Nursing confirmed the failure to monitor these devices as required. These deficiencies indicate a lack of adherence to facility policies and physician orders, potentially compromising resident safety. The facility's policies on smoking assessments and elopement prevention were not followed, leading to lapses in monitoring and assessment that were confirmed by the Director of Nursing during interviews.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that a medication room refrigerator containing narcotics was properly locked and that open medications stored in the refrigerator were labeled with a date upon opening. During an observation, it was found that the refrigerator in the [NAME] Crossings Medication Room was unlocked and contained three opened boxes of Lorazepam and an undated vial of Tubersol solution. An LPN confirmed these findings, acknowledging the failure to secure the refrigerator and properly label the medications. Additionally, the facility did not store medications and treatments properly to prevent cross-contamination on two medication carts. Opened tubes of Biofreeze gel and an Albuterol inhaler were found on a medication cart without proper labeling. Furthermore, expired insulin medications and medications not stored in pharmacy-labeled bags were found on Settlers Cart 6. An LPN confirmed the presence of expired medications and the lack of proper labeling, indicating a failure to adhere to storage and labeling protocols.
Infection Control and Communication Deficiencies
Penalty
Summary
The facility failed to properly monitor the personal refrigerators of two residents, as neither contained a thermometer or a temperature log for daily monitoring. This oversight was confirmed by an LPN during interviews and observations. Additionally, the facility did not implement proper infection control practices during a dressing change for a resident with paraplegia, diabetes, and depression. The LPN involved did not clean the bedside stand or place a barrier before placing dressings, used ungloved hands to place a barrier under the resident, and did not perform hand hygiene after cleansing the wound and applying new dressings. The facility also failed to review its infection control policies annually, with the last review dated back to 2014. Furthermore, the facility did not notify residents or their representatives about two infectious outbreaks, COVID-19 and Norovirus, as confirmed by the Director of Nursing. The resident group was unaware of the Norovirus outbreak, indicating a lack of communication from the facility regarding these health concerns.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience by not offering timely assistance with meals to two residents, R35 and R55. Resident R35, who has diagnoses of depression, malnutrition, and Alzheimer's disease, requires substantial maximal assistance with eating, as indicated by their MDS assessment. During an observation, it was noted that Resident R35 was left without assistance at a dining table with their meal in front of them, while four staff members were occupied assisting other residents. Similarly, Resident R55, who has high blood pressure, diabetes, and dementia, is completely dependent on assistance for eating, as per their MDS assessment. This resident was also observed sitting at a dining table with their meal in front of them without receiving the necessary assistance. A nursing assistant acknowledged the lack of staff to assist with feeding and had not yet reported the need for additional help. The Assistant Director of Nursing confirmed the facility's failure to provide timely meal assistance, thus compromising the residents' right to a dignified dining experience.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for one resident. The resident, who was admitted with diagnoses of hyperlipidemia and depression, was found to have skin issues including scratches on the right hip, raised patches on the abdomen and right side, and a yeast infection under the left breast. These conditions were noted by an aide and confirmed by a registered nurse, who instructed the application of anti-fungal and barrier creams. However, there was no documentation indicating that the physician was notified of these changes in the resident's condition. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Ensure Understanding of SNF ABN Form
Penalty
Summary
The facility failed to ensure that residents were given proper notice and understanding of their Medicaid/Medicare coverage and potential liability for services not covered. Specifically, the facility did not adequately explain the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form to Resident R84, who had a BIMS score of 8, indicating moderate cognitive impairment. This score suggests that the resident may not have fully understood the implications of signing the SNF ABN form without proper explanation or assistance. The deficiency was identified during a review of facility admission documents and staff interviews. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the facility did not ensure the SNF ABN was explained in a manner that Resident R84 or their representative could understand. This oversight was in violation of several Pennsylvania Code regulations related to admission policy, licensee responsibility, management, and resident rights.
Failure to Obtain Physician Order for Bed Placement
Penalty
Summary
The facility failed to obtain a physician order and develop a resident-centered care plan for the placement of a bed against the wall for Resident R42. The facility's policy on physical restraints, last reviewed on 11/8/24, mandates that restraints should only be used as a last resort and must be justified by medical symptoms. However, during an observation and interview on 11/14/24, it was confirmed by Nurse Assistant Employee E12 that Resident R42's bed was positioned against the wall without a physician's order. The Director of Nursing also confirmed this oversight. Resident R42's clinical record indicated diagnoses of coronary artery disease, hypertension, and hyperlipidemia. The resident's care plan, revised on 10/1/24, aimed to prevent falls but did not include the placement of the bed against the wall. This oversight was a violation of the facility's policy and resident rights, which state that residents should be free from restraints unless medically necessary. The facility's failure to adhere to these policies resulted in a deficiency as per the cited Pennsylvania Code regulations.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter. The facility's policy on indwelling urinary catheters, last reviewed on 11/8/24, requires that catheters not medically justified be discontinued as soon as clinically warranted and that catheter bags have a privacy cover unless one is built in by the manufacturer. However, during an observation on 11/12/24, it was noted that the resident's foley catheter bag was hanging on the bed frame without a privacy cover, which was confirmed by an LPN. The resident in question was admitted with a diagnosis of anemia, hypertension, and neurogenic bladder, and had a physician's order for a 16 French foley catheter with a 10cc balloon. The resident's care plan also indicated the use of an indwelling foley catheter related to neurogenic bladder. Despite these documented needs, the facility did not adhere to its policy regarding the privacy cover for the catheter bag, leading to the deficiency noted in the report.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility staff failed to maintain ongoing communication with the dialysis center for two residents, leading to a deficiency in providing safe and appropriate dialysis care. Resident R57, diagnosed with anemia, hypertension, and end-stage renal disease (ESRD), was to receive dialysis three times a week. However, the review of dialysis communication sheets revealed that two out of 21 sheets were not completed prior to dialysis sessions. Similarly, Resident R59, diagnosed with heart failure, hypertension, and ESRD, also required dialysis three times a week. The review showed that 18 out of 20 communication sheets were not completed before dialysis sessions. During interviews, an LPN admitted that the top portion of the dialysis sheets was not normally filled out, while an RN acknowledged the necessity of completing this section and sending the book along with any order summaries. The Director of Nursing confirmed the incompleteness of the dialysis books and the failure to maintain communication with the dialysis center for the two residents. This lack of communication and documentation was identified as a deficiency in the facility's compliance with the required standards for dialysis care.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by the case of one resident who did not receive their prescribed medication, Mercaptopurine, on two consecutive days. The facility's policy requires that physician orders are followed and medications are administered as prescribed. However, the resident's Medication Administration Record indicated that the medication was not available on the specified dates, leading to missed doses. Additionally, the clinical record did not show any evidence that the physician was notified about the missed doses of Mercaptopurine. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the failure to prevent significant medication errors for the resident in question. The deficiency was identified under several Pennsylvania Code regulations related to nursing services, resident rights, resident care policies, and pharmacy services.
QAA Meetings Lacked Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for the period of January 2024 through March 2024. The facility's policy, dated 7/22/24 and last reviewed on 11/8/24, mandates that the QAPI Committee should include specific members such as the Nursing Home Administrator, Director of Nursing, Medical Director, and others. However, a review of the QAPI Committee meeting sign-in sheets revealed that the Medical Director/designee and Infection Preventionist were not in attendance during this period. This deficiency was confirmed by the Nursing Home Administrator during an interview on 11/15/24.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quality Life Services - Sugar Creek | 4.9 mi | ★★★★★ | 13 | 1 |
| Sunnyview Nursing And Rehabilitation Center | 9.7 mi | ★★★★★ | 8 | 0 |
| Concordia Lutheran Health And Human Care | 11.6 mi | ★★★★★ | 0 | 0 |
| Advanced Care Center Of Butler | 12.6 mi | — | 0 | 0 |
| Quality Life Services - Sarver | 13.7 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.